Trauma and loss collide in episodes of mass violence. Emotional wreckage for the loved ones of those lost, heartbreak for the first responders, and gaping wounds in communities converge to create a phenomenon distinct from other losses.

The tears still come when Celeste Peterson looks back—and even when she doesn’t—to the day six years ago when her daughter was killed in the nation’s deadliest school shooting: the massacre at Virginia Tech. A former high school varsity basketball player and team captain, 18-year-old Erin Peterson was a daddy’s girl and the light of her mother’s life.

The afternoon of April 16, 2007, was like any other. An only child, the freshman international studies major had gone to French class, where she and most of the other 32 victims were murdered by student Seung-Hui Cho, while many more were injured. In an instant, countless lives were affected by one man’s actions.

These tears, like those shed by the parents, children, siblings, and friends of the victims of a sorrowful succession of mass shootings and the recent attacks in Boston—the tears we see with shocking frequency on the nightly news and those we may shed ourselves in empathy—reveal the lie that grief, and particularly traumatic grief, follows a specific course and resolves at a predictable point—or that it resolves at all. As Mila Ruiz Tecala, LICSW, an authority on grief, says, “The word ‘closure’ was invented by the media. There is no such thing.”

But there is healing—and healing again after wounds reopen—as they often do for the loved ones of the victims of mass violence. Social workers can play a significant role in facilitating that healing, whether on the scene after an event as members of highly trained crisis intervention teams or, more often, months and even years after the events when trauma lingers or the lives of people who thought they had moved forward begin to unravel.

On the Front Lines
Providing information and helping refer people to counseling services and bereavement support groups are among the ways social workers can assist following mass violence, says Nancy Boyd Webb, DSW, BCD, RPT-S, the distinguished professor of social work emerita at Fordham University Graduate School of Social Work in New York. She adds that in situations involving children, social workers can educate parents and teachers about children’s typical responses after traumatic events.

In the immediate aftermath, there may be a temptation for local social workers to offer help and support, but crisis management on the front lines and in the first hours and days after a tragedy is a task that should be reserved for clinicians specially trained in traumatology, according to Tecala.

Even those with advanced training can be swamped and overcome by the intensity of tragic events, stresses Tecala, who operates the Center for Loss and Grief in Washington, DC. “When 26 people are killed and 20 are children, for example, it is overwhelming, and whenever children are involved it’s always harder for first responders.” She recommends alternating days of service with days for respite. She says it’s crucial because when you overwhelm your psyche, you can’t help others.

Coping With the Fallout
Experts agree that the key to helping the loved ones of victims of mass violence is to understand the unique qualities of traumatic grief. In more typical circumstances, a death may be seen as a natural event, and there may be time to anticipate grief and say good-bye. Mass shootings or other mass violence, in contrast, cause sudden, shocking loss. Survivors and family members, who are sometimes neighbors or fellow community members, often mourn the loss of multiple victims and engage with others similarly bereft, becoming engulfed by tragedy.

Grieving for these unimaginable losses is different, compounded, and complicated. Curt Drennen, PsyD, RN, a clinical psychologist and manager of Disaster Behavioral Health Services, Office of Emergency Preparedness and Response, Colorado Department of Public Health and Environment, defines normal grieving as a process, recreating the cognitive schema around the meaning of life, the relationships in life, and the expectations associated with those relationships. Part of the grieving process involves restructuring a life without the deceased. But after mass violence, Drennen says, “when someone you love goes to the theater or to school expecting a normal situation and that normalcy is shattered by violence that takes life, there’s the additional impact of the scene of an intentional event in which a perpetrator purposely set out to cause pain, suffering, and harm.” Following such a traumatic event, you also have to restructure how you perceive the world and your expectation of safety, he adds.

Tecala says another key difference is that the death resulting from a mass shooting or other attack involves mutilation, a harrowing detail on which mourners dwell. The traumatic event itself, Webb notes, “causes survivors to focus on the horror and the tragedy. Waiting for identification of the bodies is an excruciating experience.”

The Petersons, for example, learned about the Virginia Tech shooting at 9:26 am on April 16. It wasn’t until the next morning, after an agonizing night, that they learned the cruel fact that their daughter was among the casualties.

These circumstances form “a constellation of high-risk factors that will catapult a family not only into having to deal with grief but also with trauma,” says Therese Rando, PhD, BCETS, BCBT, a clinical psychologist, thanatologist, and traumatologist and the author of numerous books on bereavement.

Many professionals consider traumatic grief to be normal when it follows certain abnormal circumstances, says Rando, whose new book, Coping With the Sudden Death of Your Loved One: Self-Help for Traumatic Bereavement, guides the bereaved and the mental health professionals who treat them. “But when trauma and loss collide, as they do in a circumstance such as a mass shooting, it creates a different phenomenon. It’s not just trauma plus loss.”

The critical part is the interaction between trauma and loss. Recognizing the effect of that interplay and the reverberations it creates is the job of any social worker working with the families after mass violence. “You have to deal with the demands of trauma and trauma mastery, and deal with the loss and the accommodation of grief and mourning, and also look at the way they influence each other,” Rando explains.

One way this interplay complicates bereavement is that the strategies for coping with trauma often are at odds with those for coping with grief and vice versa, according to Rando. In normal grieving, for example, the bereaved want to recollect and reminisce about their loved ones, but thinking about the person may be exactly the thing that families traumatized by a shooting death need to not do.

“Every time they think about that person, they might have an image or a kind of sensory reaction. If they’d been in the area and smelled the ammunition or heard the cries, for example, those sensory reactions could overcome them so that they end up stifling the grief,” Rando says. They don’t want to go there in their minds, to remember, she explains, because every time they do, they have horrific images or think about the agony or fear their family members experienced. The reminiscing that’s so important in grief work may “end up causing more distress and make them more vulnerable and more able to be revictimized,” she says.

In traumatic deaths, the details of the trauma predominate initially, Rando says, and these preoccupations can interfere with the normal grieving process that involves remembering the deceased. Clinicians can’t simply deal with the trauma piece and then deal with the loss piece and be done, she adds.

“It’s not enough to have an awareness of loss in general or to take a good loss history,” Rando notes. “You’ll have to look at the intersection of trauma and loss, at how the traumatic stress is interfering with the grief, and vice versa, and what kinds of strategies people will need to cope. In this interaction, the whole is more than the sum of its parts.” It doesn’t mean they can’t ultimately successfully accommodate the loss, “but they’ll have a lot more to do to be able to get to that point, and more places where they can get derailed.”

Take It Slowly
Drennen says a first step is to determine how long it’s been since the traumatic event occurred, where individuals are in the grieving process, and whether they’re ready to talk. In the first few days, and perhaps for much longer, the individuals’ brains are trying to process the information at the same time they’re trying to protect themselves from the suddenness of the trauma, Tecala explains. “Sometimes people seem to deny, to be in a daze, but these are all coping mechanisms,” she adds.

Webb agrees that in the immediate aftermath of a violent event, few people are ready for counseling. “They are in a state of shock and can barely get through the day.” She points to poor attendance at bereavement counseling set up by agencies just after the 9/11 attacks. “Families initially want to hunker down and be with their family members and close friends. After six to eight weeks, it may be more appropriate to offer bereavement support groups.”

According to Drennen, “When there are people we can connect with as clinicians who have experienced such a public trauma, we can put the blinders on and feel such an impulse to help this person that we forget the need to take it slowly, to allow the individual to dictate what the need is, to really listen and allow them to articulate what their struggles are.” He adds that it’s also important for clinicians not to assume to know what the struggles are because every person’s needs can be different than what you expect they may be.

Clinicians also must acknowledge a tendency to overpathologize normal reactions, Drennen adds. Research shows that hyperarousal, reactivity, and intrusive memory happen to most people after these extreme experiences, he says. “They will respond in surges and to triggers and associated events with sadness, anxiety, despair, and anger—all very normal reactions. What turns those reactions into a disorder is the avoidance of the experience. It’s when a person starts withdrawing where things become problematic.”

Staying Attuned to Signs of Struggle
“Right after an event, you have a spike in altruism, a kind of honeymoon phase,” Drennen says, where resources pour in and families of victims get a surge of support. “But then as the media and first responders pull away, there’s disillusionment and those remaining now have to take stock of the loss.”

It’s then that mental health professionals must be particularly vigilant to the needs of their clients, for whom the reality of the situation is beginning to sink in. Look for symptoms that get in the way with functioning, Tecala says, such as signs of insomnia or sleep disturbances, anxiety, forgetfulness, poor concentration, or loss of appetite.

In addition to counseling, she says it’s helpful to provide handouts with coping strategies. “Most people don’t remember what you tell them in times like this,” she explains. “It’s too overwhelming and goes in one ear and out the other, assuming they hear it in the first place. If they have something to hold onto and read, it can be a helpful reminder.”

Also be alert for signs of complicated grief in people months and even years after a traumatic event, Rando advises. For example, consider the person who has lost interest in normal activities or who is going through a divorce.

Be aware as well of patients either focused on reliving the trauma or avoiding anything that might remind them of it. Webb also cautions that anniversaries, holidays, birthdays, and other special occasions will elicit sorrow about the deceased. For example, “the 9-year-old boy who was very overcome when he started baseball practice and realized that the father of all the other boys on the team were there except his.”

Experts observe that traumatic events result in what Tecala calls a loss of the sense of invulnerability—a loss that rarely can be repaired. Individuals likely will live with anxiety and anticipation about future violent events, no longer feeling safe. She advises clinicians to stay alert to signs of hypervigilance and be mindful of the signs of grief emerging long after a loss, particularly when new events tear at old wounds. A violent loss, she suggests, is like a scab. “You hit the scab and it bleeds all over again.”

“It’s true that grieving lasts forever, and future exposure to other deaths can bring up sad memories of one’s own losses,” Webb says. “This is normal, and clinicians can help by normalizing the experience. It means that the survivors are human. They also can be helped to take pride in the fact that they have been able to carry on with their lives and have learned to keep their loved ones in their heart.”

Mourners can feel defeated or abnormal if they don’t accommodate the loss on the schedule or in the manner others seem to think appropriate. “Clinicians should emphasize that different people will express their feelings differently, and that there is no one right way to grieve,” Webb says. Clients can be encouraged to tune out messages from experts or well-meaning friends who suggest that they must mourn in a certain way or for a certain time.

Mourning is very idiosyncratic, Rando says. Those suffering traumatic bereavement require more time and understanding, she says, as well as appreciation for all the dynamics they’re dealing with. Even people in the same family will grieve differently. There’s a danger, she suggests, “in failing to grasp that their mourning will be as unique as their fingerprints.”

Secondary Grief
Clinicians may need to not only counsel the families of victims of mass violence but also address the needs of those experiencing secondary grief, or the swelling of emotion experienced by individuals with no direct involvement in the tragedy but were exposed to and affected by it through the media. Charles R. Figley, PhD, the Paul Henry Kurzweg, MD, distinguished chair in disaster mental health at Tulane University in New Orleans and the Graduate School of Social Work professor, describes it as a reaction akin to “collective compassion—being touched by an event in ways similar or the same as the reactions of others in a community.”

Media reports, particularly television, “can bring about an emotional proximity that can produce associated symptoms of anxiety and depression,” Webb says. “So a traumatic situation such as occurred in Newtown may have far-reaching effects on people who were geographically distant but who felt connected by seeing scenes of the evacuation of the students and witnessing the public grieving of parents and the community.”

According to Tecala, individuals often experience secondary grief when they have unresolved grief in their lives. When something, such as news reports of mass shootings, triggers those feelings, they experience real grief, even if they don’t know the victims. And for those who have experienced traumatic grief in the past, new tragedies can open old wounds. Tecala recalls, for example, a patient whose son was killed in the World Trade Center. For the first year, every time she saw news reports about people who died—deaths not in any way connected to 9/11, she’d cry. “She wasn’t crying for those people,” Tecala says. “She was crying for her son.” Clinicians can help these individuals by suggesting that they limit how much time they spend watching television and avoid the continual media replay of traumatic events that can hinder healing.

Be mindful as well of the effect of media coverage on those directly affected by the traumatic event. “Grief is on display in public and private settings. Most often, the grieving are in a fog mentally and physically,” says Figley, who also is the director of the Traumatology Institute at Tulane University. “Public support breaks through the fog because it shifts the grieving from someone who lost so much to someone with the responsibility of expressing this to others. Often, they run out of others to process their grief. Community outpouring is a wonderful distraction as well as a reminder of their importance to the community,” he adds.

“There is a collective grief that enables families to feel that they are not alone but at the cost of vicariously experiencing the grief of other families like them,” Figley continues. “The net effect is positive for the short run, but in the long run there will be huge variations in families’ abilities to move on in their lives and to salvage real joy again.”

— Kate Jackson is an editor and freelance writer based in Milford, PA. She has written for Social Work Today on topics such as grief and loss, mental health, compassion fatigue, and the emotional aspects of illness.